J Bone Joint Surg Am 1995 Sep;77(9):1374-1379 Department of Orthopaedics, University Hospital Maastricht, The Netherlands.
The results of the operative treatment of medial epicondylitis in forty consecutive elbows (thirty-eight patients) were assessed retrospectively on the basis of the subjective outcome, pain noted during resisted palmar flexion of the hand and wrist, satisfaction of the patient, and grip strength. The mean age of the patients at the time of the operation was forty-two years (range, twenty-two to fifty-six years). Coexistent ulnar neuritis was identified preoperatively in twenty-four elbows. The operative procedure involved release of the attachment of the common flexor muscle of the forearm at the medial epicondyle in all of the elbows and release of the retinaculum over the cubital tunnel in seventeen of the twenty-four elbows that had coexistent ulnar neuritis. The patients were followed for a mean of forty-four months (range, twenty-four to sixty-seven months). Twenty-five elbo
ws had a good over-all subjective outcome. The preoperative pain had resolved in twenty-eight elbows. The over-all subjective outcome was less favorable for the elbows that had had coexistent ulnar neuritis (p < 0.05). Eleven of the sixteen elbows that had had isolated medial epicondylitis and had been treated with a flexor release were free of symptoms at the time of follow-up, compared with only three of the twenty-four elbows that had had coexistent ulnar neuritis. This difference was significant (p < 0.01). Moreover, in fifteen elbows, the symptoms of ulnar neuritis persisted. There was no difference in grip strength between the treated and contralateral extremities.
J Bone Joint Surg Am 1995 Jul;77(7):1065-1069 Mayo Clinic, Rochester, Minnesota 55905, USA.
We performed a retrospective review of the long-term results of operative treatment of medial epicondylitis in thirty elbows (twenty-six patients). Sixteen elbows had concomitant ulnar neuropathy. All of the patients had tenderness over the medial epicondyle. The most sensitive provocative maneuver was resisted pronation of the forearm (a positive result for twenty-eight elbows), followed by resisted flexion of the wrist (a positive result for twelve elbows). The operative findings included an inflammatory focus in seventeen elbows and focal ulnar-nerve compression in nine. Debridement of the origin of the flexor-pronator tendon mass, with decompression or transposition of the ulnar nerve when indicated, was associated with an 87 per cent rate (twenty-six elbows) of good or excellent results at an average of seven years (range, two to fifteen years) after the operation. Twenty�
45;four of the twenty-five elbows that had no or mild associated ulnar neuropathy (type-IA or IB medial epicondylitis) had a good or excellent result, while two of the five elbows that had moderate or severe associated ulnar neuropathy (type-II medial epicondylitis) had a good or excellent result. This difference was significant (p = 0.009). Nine patients (nine elbows) needed more than six months before maximum improvement was obtained.
Int Orthop 1995;19(2):69-71 Princess Elizabeth Orthopaedic Hospital, Exeter, England.
Ninety-five cases of medial epicondylitis are reported in 83 patients; 90% were related to work and only 10% to sport or leisure activities. Most recovered with conservative treatment. Operation was needed in 12%, which compared with under 4% of patients with lateral epicondylitis over the same period. The results of open release of the common flexor origin were good, with only one exception.
Am J Sports Med 1994 Sep;22(5):674-679 School of Medicine, Dalhousie University, Nova Scotia, Canada.
Flexor and extensor muscle-tendon unit activity at the elbow during the golf swing was recorded from subjects with and without medial epicondylitis. There was no significant difference in total swing time between symptomatic (1.23 +/- 0.15 sec) and asymptomatic (1.15 +/- 0.13 sec) subjects nor between golfers with low (1 to 6 handicap, N = 8) and high (11 to 19 handicap, N = 8) scoring abilities. Symptomatic and asymptomatic subjects displayed similar electromyographic profiles for flexor and extensor muscles of the forearm. Electromyographic activity of the common extensor muscles was persistent throughout the four swing phases, ranging from 33.59% of maximum voluntary contraction at address to 58.77% at contact. Common flexor muscles produced a consistent burst of electromyographic activity during contact phase (flexor burst, 90.77&#
037; of maximum voluntary contraction). Symptomatic subjects' mean flexor muscle electromyographic activity was significantly greater than that of asymptomatic subjects in both address and swing phases. When forearm brace and oversized grips were imposed on symptomatic subjects, there was no significant difference in mean electromyographic magnitude or muscle activation pattern during the golf swing. Thus, the method of symptomatic relief of the intervention strategies tested is still in question.
Z Unfallchir Versicherungsmed 1993;86(3):145-148 Service de chirurgie, Hopital des Cadolles, Neuchatel.
Medial epicondylitis is rather uncommon, less frequent than external epicondylitis. For this reason, the diagnosis is thought of rather late. While taking the history, one should try to find out the possible causative effects. Symptoms of irritation of the cubital nerve, which are present in one out of five cases should be looked for. Several sports such as baseball, javelin or weight throwing, volleyball, climbing, tennis, golf, which need a strong flexion of the hand and fingers can induce this condition. However, in more than half of our patients, sports or professional activities were not in cause. The majority were housewives and do-it-yourself enthusiasts. Among our 55 operated cases, out of which few had professional or sports activities, we did not encounter during the operation the macroscopic tendinous lesions that are sometimes described by some authors. The treatment should be
conservative in all cases. This includes rest, anti-inflammatory drugs, physiotherapy, muscular stretching, immobilisation in a cast, steroid infiltrations. One patient out of ten will have to be operated on. The operative techniques differ on some details, but they all include the desinsertion of the flexor muscles on the medial epicondyle. When there are clinical signs of irritation of the cubital nerve, it should be transposed anteriorly. The result of these operations is good in more than 90 per cent of the cases. However, a come back to professional sport can take as long as 8 months.
J Bone Joint Surg Br 1991 May;73(3):409-411 Department of Orthopaedics, University of Southern California School of Medicine, Los Angeles 90033.
We reviewed 35 of 38 consecutive patients who had operative treatment for medial epicondylitis of the elbow after the failure of conservative management. Their mean age was 43 years and mean follow-up was 85 months. At operation residual tears with incomplete healing were consistently found in the flexor origin at the medial epicondyle and microscopy showed reactive fibrous connective tissue with varying degrees of inflammation. The mean subjective estimate of elbow function was improved from 38% to 98% of normal, while isokinetic and grip strength testing in 16 patients showed no significant difference from the unoperated elbow. Results were excellent in 25 cases, good in nine and fair in one; 86% of the patients had no limitation in the use of the elbow.
Clin Sports Med 1987 Apr;6(2):259-272 Department of Orthopedic Surgery, Boston University Medical Center, Massachusetts.
Tennis elbow is a common condition, with the extensor carpi radialis brevis attachment being the usual site of pain. Conservative care including decreased activity, ice, nonsteroidal anti-inflammatory medications, and muscle strengthening will help most people. The small percentage of cases that require surgery usually benefit from debridement of the damaged portion of the extensor carpi radialis brevis attachment. The postoperative course must include muscle strengthening and a gradual return to activity.
Am J Sports Med 1995 Mar;23(2):214-221 Virginia Sports Medicine and Rehabilitation Institute, Arlington, USA.
Fifty cases in 48 patients of intractable medial tennis elbow tendinosis (medial humeral epicondylitis) were treated surgically from 1985 to 1990 with identification and excision of the injured tendon, while retaining and closing the resection defect. All patients had symptoms that were aggravated by repetitive upper extremity activities and had failed to improve with nonoperative therapy. At surgery, the flexor carpi radialis-pronator teres interval was involved in 28 cases. Histologic examination revealed angiofibroblastic tendinosis and fibrillary degeneration of collagen. Postoperative followup averaged 37 months. An analog scale was used to analyze pain intensity, and pain occurrence was evaluated by a pain phase scale. All patients reported partial or complete pain relief postoperatively (improvement in their pain phase and pain intensity scales). Preoperatively, 14 patients had pain at rest; all 14 had relief of this
pain postoperatively. Ten patients did not return to their sporting or occupational activities. Objective dynamometer strength testing revealed a significant improvement postoperatively in all patients; no major complications were seen in this series. A large percentage of patients who fail conservative treatment for medial humeral epicondylitis (tendinosis) can obtain pain relief and return to activities with the described operative technique.
The results of operative treatment of medial epicondylitis.
Kurvers H, Verhaar J
Operative treatment of medical epicondylitis. Influence of concomitant ulnar neuropathy at the elbow.
Gabel GT, Morrey BF
Medial epicondylitis of the elbow.
O'Dwyer KJ, Howie CR
Medial epicondylitis. An electromyographic analysis and an investigation of intervention strategies.
Glazebrook MA, Curwin S, Islam MN, Kozey J, Stanish WD
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[Article in French]
Tschantz P, Meine J
Surgical treatment of medial epicondylitis. Results in 35 elbows.
Vangsness CT Jr, Jobe FW
Lateral and medial epicondylitis of the elbow.
Leach RE, Miller JK
Resection and repair for medial tennis elbow. A prospective analysis.
Ollivierre CO, Nirschl RP, Pettrone FA